Time is crucial in the collection, delivery, and distribution of whole
blood for large numbers of traumatic casualties. From 1965 forward, the
stimulus behind the plans for a whole blood distribution program to support
U.S. forces in the war in Vietnam was the need for speed. Blood is perishable,
and its useful life is short. From donor to patient, liquefied whole blood
has a life expectancy of 21 days. Still, the most desirable blood for transfusion
is the freshest blood available of the group and type specific for the
recipient, completely and accurately processed and cross matched- a combination
of perfections difficult to achieve in war.

Evolution of the System

The dominant conviction of the early blood program planners in USARPAC
and USARV was that whole blood requires professional surveillance in handling
from the moment it is drawn from the donor until the moment it is administered
to the patient. Contaminated blood can be lethal.

By 1965 and the buildup of forces in Vietnam, the time had come to move
with haste. Fortunately for the planners, requirements for whole blood
increased slowly in 1965 and not with the same explosive force experienced
at the beginning of the Korean War. Another asset was the substantial number
of directives and guides already written and the existence of the Military
Blood Program Agency.

Colonel Neel, Surgeon, USMACV, Major (later Colonel) Frank W. Kiel,
MC, Commanding Officer, 406th Mobile Medical Laboratory, Vietnam, and Colonel
Joseph F, Metzger, MC, Commanding Officer, 406th Medical Laboratory, Japan,
in late 1965, were guided by three major principles based on experience
gained thus far in the collection, processing, handling, and distribution
of blood for troops in Vietnam. These medical officers, however, could
not envision that requirements for whole blood would climb slowly but steadily
from less than 100 units per month in 1965 to 8,000 units by February 1966,
skyrocket to more than 30,000 units per month by 1968, peak at 38,000 units
in February 1969, and fall rapidly to less than 15,000 units by mid-1970.(Chart
12)

115

CHART 12- UNITS OF BLOOD AVAILABLE IN SOUTH
VIETNAM, BY MONTH,
JANUARY 1965-DECEMBER 1970 1

1Includes shipments
from the continental United States, the Pacific
Command, and blood collected in South Vietnam.Source: Report, US Military Whole
Blood Program in support of Combat Operations
South Vietnam, 1965-1970, prepared for the
Deputy Surgeon General, February 1971.

The first guiding principle was that a source of whole blood outside
Vietnam and the Pacific Command was essential. Donor resources in the Pacific
could not meet the demands for whole blood during the buildup. Second was
the establishment of a central depot in Saigon where all whole blood shipped
from Japan could be received, transshipped, and distributed for use in
the field. Third was the need for a system of forward mobile blood storage
subdepots operated by the Army and colocated with hospitals and medical
units in the Army, Navy, and Air Force along the South Vietnam coast.

A single American hospital in Vietnam, the 8th
Field Hospital, administered all whole blood
transfusions until the spring of 1965. Every
10 days, 10 units of universal donor low titer
group O blood were shipped to the hospital from
Japan to meet the small demand for transfusions.
Seldom did the demand for blood exceed the supply,
and even during the surprise attacks by the Vietcong
at Qui Nhon and Pleiku, in February 1965, the
406th Mobile Medical Laboratory bled local donors
to supply the needed 123 units of whole blood.
After the 3d Field Hospital arrived in Saigon
in May 1965, it became the central blood depot
in Vietnam, and the 406th Mobile Medical Laboratory,
a satellite of the 406th Medical Laboratory in
Japan, was charged with distributing whole blood
to all US forces in Vietnam.

116

In the meantime, with the expanding need for
blood, reorganization of the whole blood program
for PACOM (Pacific Command) was underway. Colonel
Metzger was also designated Blood Program Officer,
PACOM, with direct responsibility to CINCUSARPAC
(Commander in Chief, US. Army, Pacific) for the
co-ordination and integration of plans, policies,
and procedures to insure blood for all areas
in USARPAC, including USARV.

The embryonic whole blood distribution system in Vietnam, continued
to expand and by 1967 was serving all Free World forces in Vietnam, excluding
the RVN Arm which met its own blood needs. The responsibility for supervising
and operating the central blood bank in Vietnam came under the, technical
direction of Colonel Hinton J. Baker, MC, Commanding Officer, 9th Medical
Laboratory, 3d Field Hospital, Saigon. The USARV Central Blood Bank operated
under the parent laboratory's 9th Medical Laboratory Detachment and was
supported by personnel from the 3d and 51st Field Hospitals, and five subdepots
in the blood distribution system: the 406th, 528th, and 946th Mobile Medical
Laboratories at Nha Trang, Qui Nhon, and Long Binh, respectively; the Naval
Support Activity Hospital, Da Nang; and the 96th Evacuation Hospital, Vung
Tau.

As troop strength grew and combat casualties increased, the task of
distributing whole blood, plasma, and related products in South Vietnam
developed into the largest blood distribution system ever undertaken by
a single organization.

Colonel James E. McCarty, MC, became Blood Program Officer, PACOM, in
June 1968 and commander of the 406th in Japan at the same time. He and
his predecessor, Colonel Metzger, visited South Vietnam regularly, conferred
with the surgeon, and inspected blood facilities throughout the country.

Initial Sources of Whole Blood

The primary source for whole blood used in South Vietnam until July
1966 was the 406th Medical Laboratory in Japan. Mobile bleeding teams were
dispatched from the laboratory to donor resources in Japan, Korea, Okinawa,
and Taiwan. A very valuable donor resource was found in the Yokosuka Naval
Base when the Pacific fleet came in, and reserve donor resources also existed
in Hawaii, Guam, and the Philippines. With vigorous command support and
the dedicated work of blood-drawing teams, supply kept, pace with demand
until June 1966. Blood collections in, PACOM rose from 201 units in January
1965 to 7,426 in January 1966 and 12,984 in June 1966.

Blood collected in PACOM was processed and shipped from the 406th in
Japan to large troop concentrations along the coast of South

117

Vietnam at Saigon, Nha Trang, Qui Nhon, and
DA Nang. By 1965, it was apparent that this plan
would not work because aircraft could not be
scheduled economically from Japan to each of
the four areas regularly enough to keep the supply
levels of blood at the proper level. Communications
between Japan and the coastal cities were poor,
and shipments of blood often arrived in Vietnam
without the knowledge of those persons handling
it. Planners had also become sharply aware that
blood could not be, handled as a routine supply
item even in a dedicated medical supply system.

In short, by 1965 it was clear in PACOM that the whole blood distribution
system should consist of a central depot in Saigon with several small mobile
subdepots located in areas of high troop intensity.

Agencies for Expansion of Blood Supply

The Military Blood Program Agency

In June 1966, the need for whole blood in Vietnam became urgent. Blood
donor resources in PACOM had been exceeded, and the blood program officer
estimated that 1,000 units of low titer group O blood per week would be
needed. CINCUSARPAC sent a request, to the MBPA (Military Blood Program
Agency) to ship the needed blood to the 406th.

Four years earlier, in May 1962, responsibility
for implementing and coordinating the whole blood,
program in CONUS was delegated to the Secretary
of the Army by the Secretary of Defense. Hence,
The Surgeon General of the Army established the
MBPA on 17 July 1962 to support emergency requirements
for whole blood in war. The agency, staffed by
medical officers of the three services, maintained
close working relationships with the US Public
Health Service, the Office of Emergency Planning,
Executive Office of the President, and the American
Red Cross.

Armed Services Whole Blood Processing Laboratory

The MBPA incorporated the donor collection and processing capabilities
of the three military departments. Blood was collected by 42 donor centers
designated by The Surgeons General of the Army, Navy, and Air Force and
shipped by air to the triservice ASWBPL (Armed Services Whole Blood Processing
Laboratory), McGuire Air Force Base. (Chart 13) All group O blood
was titered, and after a thorough inspection and verification of groups,
Rh types, and other essentials, blood was flown via Elmendorf Air Force
Base, Alaska, to Yokota Air Force Base in Japan. At each point, shipments
were, re-iced, if necessary, and flown to the 406th Medical Laboratory
in Japan. From Japan, whole blood was

flown to the 9th Medical Laboratory, Saigon, and distributed from there
to subdepots in South Vietnam.

The first shipment of whole blood, 2,036 units, arrived in Japan from
the United States in July 1966.

From July 1966 to 1967, two shipments of 1,500 to 2,500 units of whole
blood were received from CONUS each week. To boost blood needs, Colonel
Metzger recommended in 1967 that daily shipments to total 5,000 units each
week be made from CONUS to arrive in Japan early in the morning, from Mondays
through Fridays. Daily shipments began in mid-August 1967. The total number
of units of blood collected and shipped to Vietnam are shown in Table 9.

TABLE 9.-NUMBER OF UNITS
OF BLOOD COLLECTED AND SHIPPED, BY YEAR, TO
THE CENTRAL BLOOD BANK IN VIETNAM BY THE 406TH
MEDICAL LABORATORY, US ARMY, JAPAN

Year

Units collected 1

Units shipped

Number

Number

1966

130,308

115,869

1967

222,534

213,022

1968

399,724

351,519

1969

385,883

348,409

1970 2

73,109

59,175

Total

1,211,558

1,087,994

1 The total figures
for each year include blood shipped to the
406th Medical Laboratory in Japan by CONUS
and that collected in PACOM by the 406th. 2 Excludes blood collected and shipped
in December 1970. December statistics were
not available. Source: Report, Administrative Division,
406th Medical Laboratory, USAMC, Japan,1970.

From 1969, whole blood was flown by MATS C-141
Starlifter to Japan. This blood, plus fresh frozen
plasma and whole blood obtained by the 406th,
was flown by commercial airline to the USARV
Central Blood Bank in Saigon and after June 1969
to Cam Ranh Bay, the new location of the blood
bank. (Map 5) Blood was approximately
7 days old by this time. Most of it went forward
by C-130 fixed wing aircraft to one of the six
subdepots at Long Binh, Nha Trang, Qui Nhon,
Pleiku, Chu Lai, and DA Nang. From these subdepots,
blood of all types and fresh frozen plasma were
sent by fixed wing aircraft, helicopter, or ambulance
to the various field, evacuation, and surgical
hospitals. Low titer group

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Map 5

O positive blood was shipped from the subdepots to division clearing
stations by helicopter.

The Department of Defense, and thus MBPA, felt that blood quotas should
be assigned according to available donor resources. The military departments
originally felt that quotas should be assigned according to

121

their blood requirements. Fortunately, this problem was resolved early
and essentially the following distribution prevailed:

Agency

Army

Air Force

Navy

MBPA (recommendations)….percent..

50

30

20

Military
Departments (furnished) …Percent

51

29

20

Relocation of the Central Blood Bank

After the Tet Offensive in 1968, military officials feared that another
such offensive would interrupt the supply of blood from the USARV Central
Blood Bank in Saigon, or that the airfield at Tan Son Nhut might be seized.
Plans were initiated to construct a new central blood bank at Cam Ranh
Bay on the grounds of the 6th Convalescent Center. The new laboratory was
completed in June 1969 and the USARV Central Blood Bank moved there in
July 1969.

The building, with 1,000 square feet of laboratory floor space and 600
square feet of' cement under cover, accommodated a 1,800 cubic foot walk-in
refrigerator. The neat new structure was considered to be in a more secure
area at Cam Ranh Bay than in Saigon, and air transportation from Japan
was readily available. (See Map 5.) Maximum flexibility was achieved
by the relocation of the central blood bank. The

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3d Field Hospital, redesignated a subdepot,
could quickly revert to a central blood bank
if an emergency arose, and the subdepot at DA
Nang, after expansion, was fully capable of serving
as a central blood bank.

Group and Type-Specific Blood

In early 1965, it was decided that only universal donor low titer group
O blood would be shipped to Vietnam, and that the use of group and type-specific
blood would be confined to the offshore hospitals in Japan and in the Philippines.
The great advantage of universal donor blood is that it is impossible to
give a patient the wrong group of blood. As the requirements for blood
increased, and as hospitals in Vietnam became more sophisticated, blood
program officials decided to utilize fully the available donor population.
Less than 45 percent of the donor population had group O low titer blood,
and 55 percent of the donor population was not being bled.

The first shipments of group A blood arrived in Vietnam in December
1965, and shipments with random blood group distribution, groups A, AB,
B, and O, without selection, arrived in January 1966. The clearing companies
and forward surgical hospitals continued to use only group O low titer
blood because they could not cross, match, but evacuation hospitals began
to give other type-specific transfusions almost exclusively.

Unfortunately, random shipments resulted in
excessive amounts of group A blood in the depots
in Vietnam. With the institution of shipments
from CONUS by MBPA in July 1966, the numbers
of units of universal donor group O low titer
blood shipped to Vietnam increased, and by 1967,
shipments exceeded requirements by 65 percent.
As more and more Vietnamese were cared for in
US military hospitals, with the Vietnamization
of the combat role, a new problem with blood
group distribution arose. The requirements for
group B increased in proportion to the number
of Vietnamese admitted to American military hospitals.
The approximate percentage blood group distribution
for American and Vietnamese populations in the
following tabulation readily show that Vietnamese
required more group B blood:

Specific blood types

A

AB

B

O

American
troops…Percent

39

3

14

44

Vietnamese
troops…Percent

21

6

31

42

Transfusion Reactions

Hemolytic and Nonhemolytic Transfusion Reactions

Between March 1967 and June 1969, approximately 364,900 transfusions
were recorded. During that period, 38 hemolytic and 979 nonhemolytic transfusion
reactions were reported, or about 1 hemolytic,

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transfusion reaction per 9,600 transfusions and one nonhemolytic reaction
per 370 transfusions. Causes of the nonhemolytic reactions are unknown
and while they never threatened life, these reactions were considered detrimental
to the well-being of the severely wounded patient. The cause of these reactions
is exceedingly complex, and much research is needed in this neglected field.

The Coagulopathies

Bleeding problems, called variously the oozing syndrome, tomato juice
syndrome, or red ink syndrome, were frightening to the most experienced
battle surgeon. To see a patient suddenly begin to bleed profusely from
every orifice and wound just as heroic surgery appeared to be successful
was a dramatic experience.

Coagulopathies may be divided into two groups, if it is remembered that
the division is an oversimplification. Since coagulopathies usually occur
in combinations and rarely in the pure form, study under field conditions
is almost impossible. Coagulopathies that, respond well to fresh blood
are attributed to deficiencies of platelets or deficiencies of coagulation
principles other than platelets. The latter principles respond well to
fresh frozen plasma or fresh blood. Coagulopathies that do not respond
well to fresh blood may be attributed to circulating anticoagulants, disseminated
intravascular coagulation, or circulating intravascular fibrinolysins.

While physicians generally recognized the classification of coagulopathies,
there was little agreement about the proper treatment. One group of physicians
treated all coagulation problems with fresh blood while others differentiated
the various syndromes and used more specific treatments, such as fresh
blood, fresh frozen plasma, cortisone, heparin, epsilon, aminocaproic acid-
or prayer. Fortunately the number of patients suffering from coagulation
problems was small, but the threat after massive, transfusions and surgery
was ever present.

Fresh Frozen Plasma

In April, 1968, fresh frozen plasma was introduced in Vietnam as a means
for controlling coagulopathies following surgery and massive transfusions.
The availability of fresh frozen plasma resulted in a decrease in the,
quantity of fresh whole blood drawn in Vietnam. Fresh plasma is obtained
at the 406th Medical Laboratory in Japan by the process of plasmapheresis
from a limited group of donors of the AB group- the ideal donors for fresh
plasma. These donors may be bled every week or every other week. Blood
from them is spun down, plasma rises to the top, and red cells settle at
the bottom. While plasma is drawn off in satellite bags and frozen immediately,
red cells are returned to the donor.

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Since plasma proteins are replenished rapidly, each donor may contribute
2 units weekly for as long as 2 years, without effects . Donors in the
AB group have no isoantibodies in their plasma and it may be given to patients
of any blood type- a real breakthrough.

Wastage of Blood

The amount of whole blood outdated because, it was not used in 21 days
was frequently significant and occasionally, during lulls in the fighting,
reached 50 percent of the blood in Vietnam per month. The average amount
of outdating was approximately 29 percent with extremes of 9 percent and
50 percent.

Use, of whole blood was best during periods of greatest military activity.
While much speculation and discussion transpired about this significant
problem, the simple facts are that blood was usually from 4 to 7 days old
before it arrived in Vietnam. Outdating was difficult to eliminate because
filling requisitions instantly for subdepots throughout Vietnam was impossible.
Some waste of blood was the price that bad to be paid to assure that not
one fighting man would die for the want of blood.

Most blood 21 to 31 days old was shipped to ARVN hospitals for local
use and for Free World forces if they desired it. During the early days
of the buildup, 31-day-old blood was destroyed, but as the war progressed,
blood was converted to plasma lyophilized by the vacuum system.

Technical Research and Innovations

Lengthening the Life of Blood

Efforts were constantly made to extend the shelf life, of blood. One
of the most promising was the addition of small amounts of the amino acid
adenine which increased the shelf life of whole blood to 40 days. Blood
with such an additive was tried on a limited basis in Vietnam during 1969.
The blood was transfused to patients admitted to the hospitals at Long
Binh, and no adverse effects were found in numbers of clinical tests. As
soon as the oxygen-carrying capacity of adenine-treated red cells can be
improved, adenine may well be added to all units of

125

liquid preserved blood used in combat military blood banking. Experiments
indicate that the oxygen-carrying capacity of treated red cells may be
increased by adding small amounts of inosine.

Freezers for Fresh Frozen Plasma

The freezing compartment of an ordinary refrigerator is not cold enough
to keep fresh frozen plasma for more, than a week or two. Factor V, the
most critical of all clotting f actors, is present in the plasma, and it
deteriorates slowly at temperatures above -20°C. A small freezer, used
by construction engineers to cool steel rivets, was ideal for storing fresh
frozen plasma. Steel rivets contract when cooled and expand to give a snug
fit as they warm up. After diligent searching, enough of these freezers
were found for all hospitals in Vietnam. By July 1969, a newly designed
4-cubic foot freezer, similar to the construction engineer's freezer, was
issued in Vietnam.

The Styrofoam Blood Box

While the war in South Vietnam will be remembered
by most military men as the war in which air
mobility came of age, it will be remembered by
many people, both Vietnamese and American, as
the war of the white styrofoam blood box. The
Styrofoam blood box was introduced in late 1965
and was without question one of the most important
technical advancements to come out of the blood
distribution program. Major William S. Collins
II, director of the blood bank at the 406th Medical
Laboratory, suggested modifying the standard
disposable blood box by replacing the cardboard
divide insert with a Styrofoam insert which he
had devised. The new insert, when placed in a
cardboard shipping container, permitted shipment
of blood at the required temperature regardless
of outside temperatures. The shipping container
is easier to handle and was less susceptible
to damage or destruction. Major Collins received
$935 for his suggestion, and his innovation resulted
in a first-year savings of $56,000 and a new
flexibility in military blood banking.

The Collins box, which occupies only 3 cubic
feet and weighs only 40 pounds when filled with
18 units of whole blood and wet ice, replaced
the Hollinger box, which occupies 8 cubic feet
and weighs 115 pounds when filled with 24 units
of blood and wet ice. In addition to weighing
less, the Collins box offers other equally important
advantages: it costs only $1.40, or $98.60 loss
than the $100 Hollinger box; it is expendable
and does not have to be returned through the
system to Japan. The Collins box maintains an
adequate ice level for 48 hours, twice as long
as the Hollinger box. The castoff Collins Styrofoam
blood boxes were

126

grabbed by American servicemen and Vietnamese civilians to be used as
private iceboxes in hot and dusty Vietnam.

Significant Problems

Wet icemaking machines used to manufacture ice for blood shipments plagued
their users at all blood depots with maintenance problems. Research to
resolve the problem was started by the USARV blood program officer.

Another significant question concerned how much universal donor group
O low titer whole blood could be given to a casualty before be would have
a reaction to his hereditary specific type and group. At least one important
experiment was done at Walter Reed Army Medical Center on a small group
of men who had received from 21 to 44 units of universal donor group O
blood, but results were inconclusive.

The Donor System

For the first time in US military history, every
unit of whole blood used to support the war was
donated free of charge by military personnel,
their dependents, and civilians employed at military
installations.

Donors were not motivated by profit. No high-pressure advertising programs
were permitted, yet nearly a million and a half volunteers gave blood.
Not once was it necessary to initiate contracts for blood to be supplied
by the American Red Cross or the American Association of Blood Banks. Even
in the most difficult times, when blood requirements reached 38,000 units
a month, the civilian blood collection system was not upset by the additional
military requirements to support an ongoing war.

Most of the credit for donor recruitment must go to the young officers
and the sergeants. These dedicated individuals instilled such confidence
in their men that the fear of giving blood and the social pressures against
the war were overcome.